This article gives you an overview of Bola's Exam Note (free form) template in AI Scribe.
Table of contents:
What is an Exam Note?
An Exam Note is a type of free form clinical note that is ideal for capturing any thought or information in a comprehensive exams using Bola's multi-purpose note format
The Exam Note captures 1) the full transcript of you speaking and then 2) transforms it into Bola's clinical note format outlined below. There is also a 3) patient summary that is generated when the bullet point note is created.
An Exam Note is ideal for...
Emergency notes
Complex notes
Patient intake notes
Surgery notes
Structure of an Exam Note
The Exam Note is broken out into 5 sections:
Reason for Exam - this includes the patient's chief complaint and whether they were referred
Medical history - this section includes information on the patient's past surgeries, dental history, family history, known drug allergies, patient habits, mental status, medications currently being taken, and past diagnoses
Examination and Treatment - includes information on vital readings (blood pressure, pulse, and respiration), examinations and procedures conducted, examination findings, imaging, extraoral examination, materials and products used during the exam, medications administered to the patient, and consent to treatment
Diagnosis - this section includes the diagnosis or diagnoses and imaging results, laboratory data, physical exam findings, recognition of other clinical documentation, diagnosed conditions and cosmetic findings (such as teeth stains, misshapen teeth, etc.)
Next Steps - this last section includes recommendations from the clinician to the patient, next visits, details of the treatment plan, and referrals
Demo video